Many blame Alison Saunders, the director of public prosecutions (DPP), for last week’s ill-advised prosecution of Dr Dharmasena on the charge of performing female genital mutilation (FGM) during repair of a previously circumcised woman’s vagina after childbirth. I confess I did at first (click here). They accuse her of trumping up a charge to cover her failure to prosecute any primary cases, and contrast the delay in bringing this flimsy case to court, with the 25 minutes the jury took to throw it out.
Dr Katrina Erskine, a consultant OBGYN at Homerton Hospital, with considerable experience in treating victims (here):
“It is ludicrous to conflate anything a doctor or midwife may do at the time of delivery to a woman who has already suffered FGM with FGM itself, and it is insulting to women who have actually suffered FGM. […] It is also a diversion from what we should really be addressing, which is to try and find a way to reduce the incidence not just for girls born in the UK but worldwide.” The decision to prosecute has ‘left me with no faith in British justice’.
The president of the Royal College of Obstretricians & Gynaecologists (RCOG) writing to members and fellows yesterday (David Richmond’s letter):
“[…] this was the wrong prosecution at the wrong time of the wrong individual. It has generated an enormous degree of anger at the process, sympathy for the patient and concern for the trainee involved. It is difficult to understand how a case that took a year to bring to court was so flimsy that it took the jury less than 30 minutes to dismiss.”
But lawyers aren’t experts in FGM. This particular DPP is a woman, but she’s just a lawyer, advised by medical experts, and campaigners. It is the latter who over reached. Most have been rather quiet, but one put her head above the parapet, Lib Dem MP, Lynne Featherstone (click here):
‘Whatever the outcome of that case, the shock waves sent through the medical profession when the arrest was announced, hopefully will be very significant in making everyone in the frontline think, what am I doing? Do I know about this?’
In other words, FGM is a terrible crime and we need to publicise it to end it, so let’s prosecute an obstetrician from time to time “pour encourager les autres”.
Imagine what Lynne Featherstone would have said had Alison Saunders declined to prosecute Dr Dharmasena, and a garbled version of events had got into the public domain. The DPP was damned whatever she did.
Featherstone is typical of a certain sort of campaigner. FGM is bad, so every possible form of it is bad. Primary infibulation is a crime so re-infibulation should also be a crime. It’s understandable; no-one wants any woman to be re-infibulated against her will. But it’s hardly the main problem. As we learned last week, at least partial re-infibulation might be needed medically, and if requested by an adult women is not a million miles away from cosmetic vaginal surgery.
Other campaigners have persuaded the World Health Organisation (WHO) to include any genital piercing, or pricking with a needle, within the definition of FGM. It’s sort of logical, but it’s not common sense. When some Malaysian parent gets prosecuted for doing a tiny needle prick, perhaps to avoid their daughter getting something worse, will we still blame the DPP?
Many campaigners are understandably annoyed when men draw parallels with newborn male circumcision. They can clearly see that although that is wrong, it’s an order of magnitude less wrong and more nuanced than FGM. Why can’t they see that reinfibulation, or pricking with a needle are also wrong, but an order of magnitude less wrong and more nuanced than primary clitoral excision?
This whole trial was a mess, and should never have happened. But don’t blame the lawyers. The doctors, midwives, and paediatricians who advise them, and the campaigners who cheer them on, should look to themselves. FGM is a terrible thing. We should fight the real thing.
Control of Hypertension in Pregnancy Study
High blood pressure (BP) in pregnancy carries risks for both mother and baby, but for years doctors have been treating it without knowing what target BP to aim for. Everyone agrees with lower than 160/110 to prevent maternal stroke, but they worry about getting near normal (120/80) for fear of reducing placental blood flow and harming the baby.
Such concerns were justified by both theoretical arguments and some rather poor quality trials, but in this week’s New Engl J Med (click here or CHIPS Trial – NEJM 2015), Laura Magee and her colleagues from Canada, show they were misplaced.
The CHIPS trial compared less tight control (target diastolic 100) with tight control (target 85). It was registered here in 2008, with a planned sample size of 1028. They recruited 1030 women, but on the advice of the independent steering committee, excluded 43 women from one site due to concerns about data integrity and consent, leaving 987 for analysis. The odds ratio of the predefined primary composite outcome (fetal loss or >48 hours neonatal intensive care) with less tight control, was 1.02; 95% CI 0.77-1.35. In other words there were no fetal risks from aiming for a target diastolic of 85.
Since lower is clearly better for the mother*, we should now aim for tight control. I’m changing my policy today, and the National Institute for Clinical Excellence (NICE) will surely soon amend its advice.
Robin Hood’s contribution
I’m also proud. Nottingham University Hospitals NHS Trust sponsored the UK arm. Dozens of UK doctors and midwives (listed here), supported by the UK National Institutes of Health Research, patiently explained the uncertainty to pregnant women and their partners, recruited those who wished to participate, and followed everyone up. The UK was the highest recruiting country worldwide.
There is a rumour that the US National Institutes of Health (NIH) have just funded pretty much a repeat of the CHIPS trial. Some colleagues blame the “not discovered here” syndrome, but I think that’s unfair. Even after randomising nearly 1000 women the confidence intervals around the fetal effect in CHIPS is compatible with a 20% reduction and a 30% increase in bad outcomes with less tight control. Millions of women have hypertension treated in pregnancy every year. A repeat trial to narrow these confidence intervals is worthwhile.
I’m following a “tight control” policy, but I’ll be looking out for the US trial results.
*CHIPS didn’t prove that. Although the primary adverse maternal outcome was higher in the “less tight” group, the difference (3.7 v 2.0%) was not statistically significant. I doubt any feasible pregnancy trial could prove maternal harm, because bad maternal outcomes are rare. But many observational studies have shown that very high BP is associated with maternal strokes, and the rate of dangerously high BP (>160/110) was greater in the “less tight” group.
Second guessing the DPP
The extraordinary trial of Dr Dharmasena, the obstetric registrar, who repaired a woman’s vagina after childbirth and now finds himself accused of performing female genital mutilation (FGM), has started (click here).
The case, as presented by the director of public prosecutions (DPP) last year, made so little sense that informed commentators (click here) assumed a political motivation, and that it would either be quietly dropped or that some new detail would emerge to justify prosecution.
Perhaps the prosecutor would bring the victim to the stand to tell the court how she had begged Dr D to leave her labia unsutured, and he had said something like: “No. Your husband wants a wife with adherent labia, so I’m going to re-suture them closed.” I doubt this is the DPP’s case because we are told the alleged victim has not even made a statement. If it were, it would indeed be terrible medicine, but not FGM; operating without patient consent is assault.
Or perhaps Dr D and the husband had colluded to remove more tissue during the re-suturing. But nothing like that is alleged in the prosecution’s case, at least as summarised in the Guardian (click here).
It appears that, either at her request, her husband’s request, or at her request through her husband, or to stop bleeding, or because he thought that was what everyone else did, or as a result of some combination of these reasons, (Dr D is alleged to have changed his story) Dr D restored the anatomy the patient came in with. He couldn’t restore it to her birth state, because the labia and clitoris had been thrown away somewhere in Somalia, but the prosecutor seems to think he should have got a bit nearer to that ideal.
I confess I’ve missed the law about restoring anatomy. What would such a law say if the woman had become accustomed to her post FGM anatomy, and asked to stick with what she knew? Perhaps the midwife, Aimma Ali, who is said to have objected to Dr D resuturing the labia at all, will shed some light.
It’s tough being an obstetrician. We not only have to keep parents and family onside – everyone’s an expert in how to deliver babies – and to make every decision with half an eye on the civil courts if a bad outcome ensues, but now we also have to second guess the DPP’s idea of an acceptable anatomical result.
Today members and supporters of the Khalifa Qamar Zaman (KQZ) Legacy Institute (click here) met by the Brian Clough statue in Nottingham’s Market Square to commemorate The Prophet’s birth.
The speakers were Imam Khalid Hussain from Leicester, and Paddy Tipping, Nottinghamshire’s Police Commissioner. In the aftermath of the Paris shootings at the offices of Charli Hebdo and at the Hyper Cacher Jewish supermarket, the distribution of roses and the messages of peace and tolerance had special importance.
The effect 0f male circumcision on female HIV infection – the evidence
If it becomes obvious mid-way through a randomised trial that a new treatment doesn’t work sufficiently well to make it worth using, stopping early is good practice; we may never get a clear answer, but who cares? But if you’re planning on using the new treatment anyway, you really must finish the trial, and sort out once and for all whether it does harm.
Consider a treatment which affects husbands and wives. Treating one automatically treats the other. Evidence accumulates that it is good for the husband but results are unclear for the wife. It would be bonkers to stop when interim data showed a non-significant harmful trend for wives, on the grounds that the treatment was never going to be good for them, and then go ahead and implement it! But that’s what the authors of the only trial ever to test the effect of male circumcision on HIV transmission to the woman did (click here).
They tested the hypothesis that circumcision of HIV positive men would reduce new cases of HIV in female partners, as part of a larger trial including HIV negative men. When the HIV negative cohort closed, the investigators fretted that “continuation […] in HIV-infected men could result in stigmatization” and “determined that the conditional power to detect 60% efficacy, […] was only 4.9% and recommended that enrolment be closed.”
At that point 17/93 (18%) intervention and 8/70 (11%) control women had become infected. The difference might have occurred by chance (hazard ratio 1.58, 95% CI: 0.68–3.66, p=0.287), but if it was real, wives would surely want to know. The harmful effect is biologically plausible; the foreskin functions as a sleeve within which the penile shaft moves during intercourse to reduce vaginal and penile abrasions. But the trial stopped, and the US, WHO, and the many governments who get funds from those sources, went on to encourage male circumcision, without mentioning the possible increase in female infection risk. For the WHO fact sheet (click here).
Some circumcision advocates (e.g. here) admit that the evidence on male to female transmission is unclear, but conclude “that women will benefit from […] voluntary medical circumcision programmes in the long-term” on the basis of modelling studies like this one (click here).
But the modelling studies ignore even the possibility of increased male to female transmission. For the base case this one assumed 60% effectiveness for men, 80% coverage by 2015, and no post-circumcision behaviour change. They tested the effect of varying all these in a sensitivity analyses but not the effect of any increased male to female transmission. Am I going mad?
Let’s summarise. Randomised trials show that male circumcision reduces female to male HIV transmission by about 60%. The only trial which measured it showed a biologically plausible increase in male to female transmission of 58%, but was stopped before it gave a clear answer. Experts modelled the effect of their programmes assuming the male benefit was real, but ignoring even the possibility of increased male to female infection. On the basis of such models millions of men are circumcised, and millions of uninformed women are put at risk.
It’s enough to turn even me feminist!
By Olena Kalytiak Davis
In the 13th century Francesca da Rimini, stuck in an arranged marriage, shared the story of the knights Lancelot and Galehot’s love triangle with Queen Guinevere, with her husband’s brother Paolo. It struck a cord, and overcome by passion they began a ten-year affair. When her husband finally caught them at it, he murdered them both. In the Inferno Dante meets Francesca and Paolo in the second circle of hell, reserved for the lustful.
Davis calls this poem, one of a series about Francesca, a “shattered sonnet”, and includes it in her latest collection The Poem She Didn’t Write and Other Poems (click here).
that maiden thump was book on floor, but
does it really matter who kissed who
first or then who decided to go further?
lower? faster? naturally, we took
turns on top. now here, now there, and up
and down…once it started no one even thought to think to stop.
so, we have holes inside our souls,
but mustn’t we begin by filling others’?
god gave us lips and hands and parts
that cannot possibly be saved for prayer. nor by.
i will not name name, claim fame by how well
or who I fucked or why, it happens all the time.
and it’s you, white pilgrims, whom next galehot seeks.
fuck. we didn’t read again for weeks.
Olena Kalytiak Davis
Often a vivid story or picture carries more weight than any amount of science or ethics. This blog received more hits for some pictures of circumcision complications (click here) than for any other post. Comments about flawed newborn tongue-tie cutting trials were ignored until I drew parallels with circumcision (click here).
This is why I’m publicising this video clip of a brit milah. There’s no blood, and we don’t see the surgery. Just a few off colour jokes, men chanting over the baby’s cries, and the women’s mixed feelings. It’s been posted by the baby. He wants you to watch. Click here.